<!DOCTYPE HTML PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
<html><head>


	<title>Orthostat</title>
	<link rel="stylesheet" type="text/css" href="registration_files/orthostate.css">
<link rel="stylesheet" type="text/css" href="registration_files/jquery-ui-1.css">
<link rel="stylesheet" type="text/css" href="registration_files/jquery.css">
<link rel="stylesheet" type="text/css" href="registration_files/jquery_002.css">
<link rel="stylesheet" type="text/css" href="registration_files/jquery_003.css">
<link href="registration_files/style.css" rel="stylesheet" type="text/css">

<script type="text/javascript" src="registration_files/jquery-1.js"></script>
<script type="text/javascript" src="registration_files/jquery-ui-1.js"></script>
<script type="text/javascript" src="registration_files/jquery_003.js"></script>
<script type="text/javascript" src="registration_files/jquery_002.js"></script>
<script type="text/javascript" src="registration_files/jquery_004.js"></script>
<script type="text/javascript" src="registration_files/jquery.js"></script>
<script type="text/javascript" src="registration_files/crud.js"></script>

<meta http-equiv="content-type" content="text/html; charset=UTF-8">	<script type="text/javascript">

		window.onload = function(){

			$('#birthdate').datepicker({
				changeMonth: true,
				changeYear: true,
				showOn: 'both',
				buttonImage: 'images/calendar.gif',
				buttonImageOnly: true
			});
			
		};
	</script>
</head><body>
<div class="mainarea">
	<div class="header">
		<div class="logo">
		<div class="logo1" onclick="window.location='/orthostat/'" style="cursor: pointer;">&nbsp;</div>
	<div class="email" id="logged_user">
		<div class="clr">&nbsp;</div>
	</div>
	</div>	</div>
	<div class="midarea">
		<div class="center_div" align="center">
			<div id="register_div">
				<form name="registerupdate_form" id="registerupdate_form">
					<div id="register_header" style="padding-top: 20px;">Update Profile</div>
					<div class="add_row">
						<div class="add_column">
							<div class="field_div">
								<div class="label fl">
									First Name:
								</div>
								<div class="fl lalign">
									<input name="first_name" id="first_name" errortag="First Name" value="Shivani" type="text">
									<div id="first_name_error" class="error_div">&nbsp;</div>
								</div>
								<div class="clr">&nbsp;</div>
							</div>
						</div>
						<div class="add_column">
							<div class="label fl">
								Middle Name:
							</div>
							<div class="fl lalign">
								<input name="middle_name" id="middle_name" errortag="Middle Name" type="text">
								<div id="middle_name_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="clr">&nbsp;</div>
					</div>
					<div class="add_row">
						<div class="add_column">
							<div class="label fl">
								Last Name:
							</div>
							<div class="fl lalign">
								<input name="last_name" id="last_name" errortag="Last Name" value="Mehta" type="text">
								<div id="last_name_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="add_column">
							<div class="label fl">
								Gender:
							</div>
							<div class="fl lalign" align="left">
								<div>
									<span style="padding-right: 10px;">
										<input name="gender" id="gender" value="male" errortag="Gender" type="radio"><img class="gender_image" src="registration_files/male.gif">
									</span>
									<span>
										<input name="gender" id="gender" value="female" errortag="Gender" checked="checked" type="radio"><img class="gender_image" src="registration_files/female.gif">
									</span>
									<div id="gender_error" class="error_div">&nbsp;</div>
								</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="clr">&nbsp;</div>
					</div>
					<div class="add_row">
						<div class="add_column">
							<div class="label fl">

								Email:<br>(used for login)

							</div>
							<div class="fl lalign">
								<input class="disable_input" name="user_name" id="user_name" errortag="Email" readonly="readonly" value="shivani.mehta@gmail.com" style="width: 142px;" type="text">
								<div id="user_name_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="add_column">
							<div class="label fl">
								Date of Birth:
							</div>
							<div class="fl lalign">
																<input class="hasDatepicker" name="birthdate" id="birthdate" errortag="Birthdate" style="margin-right: 3px;" readonly="readonly" type="text"><img title="Pick a date" alt="Pick a date" src="registration_files/calendar.gif" class="ui-datepicker-trigger">
								<div id="birthdate_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="clr">&nbsp;</div>
					</div>
										<div class="add_row">
						<div class="add_column">
							<div class="label fl">
								Address 1:
							</div>
							<div class="fl lalign">
								<input name="address1" id="address1" errortag="Address1" type="text">
								<div id="address1_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="add_column">
							<div class="label fl">
								Address 2:
							</div>
							<div class="fl lalign">
								<input id="address2" name="address2" errortag="Address2" type="text">
								<div id="address2_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="clr">&nbsp;</div>
					</div>
					<div class="add_row">
						<div class="add_column">
							<div class="label fl">
								City:
							</div>
							<div class="fl lalign">
								<input name="city" id="city" errortag="City" type="text">
								<div id="city_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="add_column">
							<div class="label fl">
								State:
							</div>
							<div class="fl lalign">
								<input name="state" id="state" errortag="State" type="text">
								<div id="state_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="clr">&nbsp;</div>
					</div>
					<div class="add_row">
						<div class="add_column">
							<div class="label fl">
								Country:
							</div>
							<div class="fl lalign">
								<input name="country" id="country" errortag="Country" type="text">
								<div id="country_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="add_column">
							<div class="label fl">
								Home Phone:
							</div>
							<div class="fl lalign">
								<input name="home_phone" id="home_phone" errortag="Home Phone" value="0" type="text">
								<div id="home_phone_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="clr">&nbsp;</div>
					</div>
					<div class="add_row">
						<div class="add_column">
							<div class="label fl">
								Mobile:
							</div>
							<div class="fl lalign">
								<input name="mobile" id="mobile" errortag="Mobile" value="0" type="text">
								<div id="mobile_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="add_column">
							<div class="label fl">
								Office Phone:
							</div>
							<div class="fl lalign">
								<input name="office_phone" id="office_phone" errortag="Office Phone" value="0" type="text">
								<div id="office_phone_error" class="error_div">&nbsp;</div>
							</div>
							<div class="clr">&nbsp;</div>
						</div>
						<div class="clr">&nbsp;</div>
					</div>
					<div>
						<input name="aurtostate_submit" id="aurtostate_submit" value="Submit" onclick="saveForm('verifyregister.php','registerupdate_form');" type="button">
						<input name="aurtostate_cancel" id="aurtostate_cancel" value="Cancel" onclick="window.location='index.php';" type="button">
					</div>
				</form>
			</div>
			<div class="indicator" id="indicator" align="center">&nbsp;</div>
		</div>
	</div>
	<div class="footer">
		<div style="float: left;">COPYRIGHT(C) 2010 <span style="color: rgb(0, 32, 123);">ORTHOSTATS.COM</span>  ALL RIGHTS RESERVED. </div>
<div class="menu">
	<ul>
		<li><a href="#" class="img1">About Us</a></li>
			<li><a href="#" class="img1">Disclaimer</a></li>
			<li><a href="#" class="img3">Contact Us</a></li>
        </ul>
</div>	</div>
</div>
<div id="ui-datepicker-div" class="ui-datepicker ui-widget ui-widget-content ui-helper-clearfix ui-corner-all ui-helper-hidden-accessible"></div></body></html>